Introduction
The interpolated paramedian flap is a reliable flap for midfacial reconstruction.Reference Conley and Price1–Reference Barton3 It is based on a single supratrochlear artery. If the donor site is small, it can be closed primarily. Healing by secondary intention is a well documented and cosmetically acceptable method of allowing larger forehead defects to heal.Reference Deutsch and Becker4 However, this can be associated with prolonged healing time, wound depression and scarring.Reference Guerrerosantos5
We present a previously unreported technique involving a frontalis muscle flap and full thickness skin graft, used to close a large forehead donor site.
Case report
An 80-year-old woman was referred to our ENT out-patient department with a large tumour involving the left nasal dorsum. The lesion measured 2.5 × 2.5 cm (Figure 1).
Fig. 1 Initial lesion.
An incisional biopsy was performed, and confirmed moderately differentiated squamous cell carcinoma.
Complete excision with an interpolated paramedian forehead flap reconstruction was performed (Figure 2).
Fig. 2 Resultant defect.
The pedicle was divided three weeks post-operatively, and the 2 × 2 cm forehead defect was closed at this time. A frontalis muscle flap and full thickness skin graft were used to close the donor site.
The contralateral frontalis muscle was exposed by making a hairline incision, perpendicular to the medial defect border. An inferiorly based frontalis muscle flap was raised (Figure 3), with its attachment to the galea aponeurotica, and rotated to cover the forehead defect. The muscle flap was secured with dissolvable subcutaneous sutures. A full thickness skin graft was harvested from the redundant proximal paramedian flap pedicle, and used to cover the frontalis muscle flap.
Fig. 3 Second procedure: elevation of frontalis muscle and rotation over exposed frontal bone.
Discussion
In the nineteenth century, Labat was the first surgeon to design a forehead flap with the base centred over a unilateral supratrochlear artery.Reference Menick6 Subsequent modifications have led to the dependable paramedian forehead flap, with a narrower base and greater functional length. The flap is usually thinned without compromising its vasculature. The thinned flap allows contouring of the underlying nasal framework, enabling a superior aesthetic result.
The disadvantages of the paramedian forehead flap are the requirement for a second operation to separate the pedicle, and the donor site scar.Reference Converse and Wood-Smith7 The narrow pedicle allows primary repair of the inferior aspect of the donor site wound. The wider superior defect may not allow primary closure; although there are several available options for closure, it can be safely (and is commonly) left to heal by secondary intention.Reference Hassanpour, Mafi and Mozafari8
With respect to alternative methods of closure, Desai and Donnelly have described closure of a low glabellar defect exposing periosteum, using a series of rhombic transposition flaps.Reference Desai and Donnelly9 These rhombic flaps were cut to a depth of subcutaneous fat and rotated into the defect. This mechanism of repair also used original forehead skin, and led to an acceptable cosmetic result for the patient involved.
The importance of preservation of the frontalis muscle in preventing forehead deformity has been emphasised by Kiyokawa et al., in a discussion of closure techniques following treatment of anterior skull base injuries.Reference Kiyokawa, Tai, Tanabe, Inoue, Hayakawa and Shigemori10 In cases in which frontalis muscle was used in a flap to repair defects, loss of contour of the forehead was noted, and dermal fat grafting was required to achieve acceptable cosmesis.
Leonard has described a technique for preservation of the frontalis muscle when performing forehead flaps.Reference Leonard11 This method prevented shiny, adherent forehead skin and loss of expression, by laying grafted skin over the preserved frontalis fibres.
• The frontalis muscle flap is a novel method of closing large forehead defects created by a paramedian forehead flap
• It provides a healthy base for a full thickness skin graft, which allows good skin colour matching and an enhanced cosmetic result
The frontalis muscle flap provides a healthy bed for an overlying full thickness skin graft in the repair of large forehead defects. A full thickness skin graft would not be possible over bare bone and periosteum. The dual layer repair results in minimal wound depression. The efficient use of the forehead skin from the redundant section of the paramedian flap provides an ideal colour match, and an enhanced cosmetic result (Figure 4).
Fig. 4 Final result.
